DIARE

MELALUI PENDEKATAN DOKTER KELUARGA (DI PELAYANAN TINGKAT PRIMER)

Sumber : A primer on Family Medicine Practice, edited by Goh Lee Gan,Azrul Azwar, Sugito Wonodirekso

DIARRHOEA IN ADULTS
RELEVANCE TO GENERAL PRACTICE Diarrhoea is an affliction familiar to everyone. Most episodes are brief, self-limited and well-tolerated without need for medical attention. Diarrhoea being a self-limiting complaint, it is useful to find out why for this episode,the patient needs to see the doctor. Symptomatic treatment is often all that is necessary for acute diarrhoea. However, one should be alert for the occasional serious cause. WORKUP History Onset. It is important to establish whether the diarrhoea is an acute problem of a few days duration or a chronic one spanning some time. Timing. One should ask when the diarrhoea usually occurs. Diarrhoea occurring at night is always pathological. Nature of stools. Watery stools constitute diarrhoea whereas loosely formed stools do not and may indicate a different pathology like irritable bowel syndrome. It is also important to ask whether the stools are mucoid, blood stained or foul smelling and floating. Travel. Recent travel overseas may be etiologically important. Foods taken. Although it is often difficult to establish the source of the diarrhoea, a history of the types of food taken within the last 24 hours may be helpful. Milk and diary products can cause loose stools in the susceptible adult. If an epidemic of food poisoning occurs, information on the type of food eaten and the place where it was served will help the Ministry of Environment in its investigations. Associated symptoms. Vomiting, nausea, dizziness, colicky abdominal pain, fever, thirst indicate that a bacterial infective cause for the diarrhoea is likely.

Physical Examination
Assessing dehydration. One should look at the tongue and mucous membranes as well as the turgor of the patient's skin. A dry tongue and mucous membrane with or without a rapid pulse rate indicate that dehydration needs to be corrected. Abdomen. An examination of the abdomen for tenderness and bowel sounds is warranted to reassure the patient that there is nothing more serious. A rectal examination

is indicated if bloody diarrhoea is present. Other systems. If a systemic cause for the diarrhoea is suspected, a full examination should be done. Investigations These are not necessary for the majority of mild acute diarrhoeas. Chronic cases will require a workup or hospital referral. Stool culture and smear for cysts and organisms are useful if giardiasis or amoebiasis is suspected. Endoscopy, barium enema or barium meal may be needed for the evaluation of a chronic diarrhoea. Other investigations: Thyroid function tests, glucose tolerance tests and other endocrine tests may be necessary. MANAGEMENT The Adult Patient Most acute cases need only symptomatic treatment. These are: - Bed rest if diarrhoea is severe or frequent. - Adequate fluid and electrolyte replacement. - Drugs like kaolin, charcoal which have some absorptive properties may be prescribed. - Anti-cholinergics like Lomotil or opiates like codeine phosphate may help to relieve the symptoms if diarrhoea is severe. - Antibiotics and Flagyl are rarely indicated unless the responsible organism is identified as being bacterial or amoebic respectively. - Anti-emetics may be useful if vomiting is severe. Indications for Referral Referrals may be indicated for the following : - Severe cases which may be infectious or warranting IV fluid replacement. - Chronic cases for diagnosis and treatment. - Cases where the diagnosis is not clear.

DIARRHOEA IN INFANTS AND CHILDREN

RELEVANCE TO GENERAL PRACTICE Diarrhoea in a child has to be attended to promptly as the patient is more prone tosuffer from dehydration and its consequences. Parents may have their incorrect views of diarrhoea in their child; thus teething doesnot cause diarrhoea, contrary to what is often believed by mothers. Fully breast-fed babies may have loose stools. Their stools are explosive, contain curd and may be bright green in colour. These babies should not be treated for diarrhoea. Starvation stools should not be confused with diarrhoea.

COMMON CAUSES Milk Formula and Improper Feeding Infants vary widely in tolerance to quantity and quality of food. The contents of protein, fat and carbohydrate affect the volume of stools. Formulas high in polyunsaturated fats have looser stools than those on formula containing greater percentage of saturated fats. Also if sugar content in formula is greater than 7.2% weight per volume, stools tend to be soft and watery. With age the gut matures and tolerance to food content improves. Breastfed babies may have frequent loose stools. This is normal. Infections Infection as a cause of diarrhoea is common. It may be enteral or parental. Rotavirus is the commonest cause. If blood is associated with diarrhoea, Shigella or Salmonella should be suspected. Cholera produces profuse rice water stools. Stool culture should be done if a bacterial cause is suspected, such as dysentery, typhoid or cholera. MANAGEMENT Management begins with assessment of the severity of the diarrhoea and degree of dehydration Children above Age of One Year Mild diarrhoea (< 4 stools per day) o Continue breastfeeding if child is breastfed. o Establish cause of diarrhoea, e.g. overfeeding, dietary indiscretion, viral upper respiratory tract infection, systemic infection and food allergy. o Treat the underlying cause. If mild dehydration and child is able to retain fluids treat as outpatient. Moderate diarrhoea (4-10 stools per day) o Off solid diet. o Half strength milk o .Oral rehydration fluids, e.g. rice-water or dextrose saline solution. Oral rehydration from tablet (Servidrat): 1 tablet in 4 ounces of water, or commercially available solutions (e.g. Oralyte, Paedialyte). Give 50 to 100 mls after each stool. Severe diarrhoea (>10 stools per day) o Off solids and off milk. Only Oral Rehydration Solution (ORS). o If diarrhoea not better (consistency of stools not improved) after ORS for 2 days change to soya formula. o Must continue till at least 3 consecutive stools of normal frequency and consistency before reverting back to milk formula. o If diarrhoea recurs on restarting milk gradually, suspect lactose intolerance (usually temporary). May need to continue on soy formula for a longer duration before attempting to switch back to milk.

o Refer to hospital if no improvement or symptoms deteriorate. Infants Mild diarrhoea. not more than 1 stool every 2 hours, give 10-15 ml/ kg/hour ORS until diarrhoea stops (approximately 1 dissolved tablet of Servidrat for each liquid stool). If breastfed, continue breastfeeding. Moderate diarrhoea. > 1 liquid stool every 2 hours. Give 10-15 ml/ kg/hour ORS until diarrhoea becomes mild (approximately 1 dissolved tablet every hour or as much as patient will accept). If breastfed continue breastfeeding. Solutions should be given slowly, in sips at short intervals to reduce vomiting and improve absorption. Severe diarrhoea. refer to the hospital.

References
1. Richter JM. Evaluation and management of diarrhoea. in: Goroll et al. Primary Care Medicine, 3rd ed. Phil5adelphia: Lippincott, 1995: 357-368. 2. Goepp JG, Katz SA. Pral rehydration therapy. American Family Physician 1993;47:4: 843-848. 3. Haffezee IE. Nutritional manageent during acute infantile diarrhoea. Maternal and Child Health. June 1992:175-179. 4. WHO. Treatment and prevention of dehydration in diarrhoeal diseases - a guide at primary care level. WHO: Geneva, 1976. 5. Biloo AG. Infantile diarrhoea: management with oral rehydration. Medical Progress Feb 1986: 15-24. 6. Barnes G. The Child with diarrhoea. In: Robinson MJ, ed. Practical Paediatrics. Chruchhill Livingstone, 1990: 505-513.